Provider Demographics
NPI:1568602258
Name:OPTICAL LABORATORY, LLC
Entity Type:Organization
Organization Name:OPTICAL LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:O
Authorized Official - Last Name:HAZOURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-331-2727
Mailing Address - Street 1:618 SW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-6429
Mailing Address - Country:US
Mailing Address - Phone:352-376-5563
Mailing Address - Fax:352-376-8783
Practice Address - Street 1:618 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-6429
Practice Address - Country:US
Practice Address - Phone:352-376-5563
Practice Address - Fax:352-376-8783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-20
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29463332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6156610001Medicare NSC